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OBJECTIVE: To explore and describe acute care nurses\' decisions to recognise and respond to improvement in patients\' clinical states as they occurred in the real-world clinical environment.
METHODS: A descriptive study.
METHODS: Nine medical and eleven surgical nurses in a large Australian metropolitan hospital were individually observed during nurse-patient interactions and followed up in interview to describe their reasoning and clinical judgements behind observed decisions. Verbal description of observations and interviews were recorded and transcribed. Reflexive thematic analysis was used to analyse the data.
RESULTS: The three themes constructed from the data were as follows: nurses checking in; nurses reaching judgements about improvements; and nurses deciding on the best person to respond. Acute care nurses made targeted assessment decisions based on predicted safety risks related to improvement in clinical states. Subjective and objective cues were used to assess for and make judgements about patient improvement. Acute care nurses\' judgment of patient safety and a desire to promote patient centred care guided their decisions to select the appropriate person to manage improvement.
CONCLUSIONS: The outcomes of this research have demonstrated that the proven safety benefits of acute care nurses\' decision making in response to deterioration extend to improvement in patients\' clinical states. In response to improvement, acute care nurses\' decisions protect patients from harm and promote recovery.
CONCLUSIONS: Early recognition and response to improvement enable acute care nurses to protect patients from risks of unnecessary treatment and promote recovery.
CONCLUSIONS: This study makes explicit nurses\' essential safety role in recognising and responding to improvement in patients\' clinical states. Healthcare policy and education must reflect the equal importance of assessment for and management of deterioration and improvement to ensure patients are protected and provided with safe care.

OBJECTIVE: The oral glucose tolerance test is the \'gold standard\' for detecting gestational diabetes in Australian and International guidelines. Test completion in regional, rural and remote regions may be as low as 50%. We explored challenges and enablers for regional, rural and remote antenatal clinicians providing gestational diabetes screening to better understand low oral glucose tolerance test completion.
METHODS: We conducted a qualitative descriptive study using semi-structured interviews. Participants eligible for the study were doctors or midwives providing antenatal care in regional, rural and remote Western Australia, between August 2019 and November 2020. Interviews were recorded digitally and transcribed into a Word document. We conducted a thematic analysis after initial categorisation and deduction of themes through workshops involving the research team.
RESULTS: We found a diversity of viewpoints on oral glucose tolerance test reliability for detecting gestational diabetes. Themes that emerged were; good collaboration between antenatal clinicians is required for successful screening; screening occurs throughout pregnancy using various tests; clinicians make significant efforts to address barriers; clinicians prioritise therapeutic relationships.
CONCLUSIONS: Effective universal screening for gestational diabetes in regional, rural and remote Western Australia is difficult and more complex in practice than guidelines imply. Detecting gestational diabetes requires creative solutions, early identification of at risk women and trust and collaboration between clinicians and women. SO WHAT?: Detection of gestational diabetes in regional, rural and remote Western Australia remains poorly completed. New strategies are required to adequately identify women at risk of adverse birth outcomes relating to hyperglycaemia in pregnancy.

BACKGROUND: The ability of a nurse to make effective clinical decisions is the most important factor that can affect the treatment quality. However, several factors can affect the ability of nursing and midwifery students to make effective clinical decisions.
OBJECTIVE: This study aims to identify the confounding factors that may affect the clinical decision making of nurses and thus patient outcomes after the COVID-19 pandemic in Jordan.
METHODS: A descriptive cross-sectional design was employed in this study. An online self-administered questionnaire was distributed to 269 nursing and midwifery students selected through purposive sampling, 224 of whom completed the questionnaire. The valid and reliable nursing decision-making instrument, which consisted of 24 items, was employed to gather the data, and descriptive statistics and simple linear regression were employed for the data analysis. Data was collected from November to the end of December 2022.
RESULTS: Among the respondents, 72.8% were female, and the average age was 20.79 years (SD = 1.44). The vast majority of the respondents (94.6%) was unmarried, and 74.1% were pursuing a nursing degree. The simple linear regression analysis showed that clinical decision making had a negative and significant relationship with social media usage of an average of 6 h a day (β=-0.085). Moreover, the male nursing students obtained lower clinical decision-making scores (β= -0.408) compared with the female nursing students.
CONCLUSIONS: Social media usage and gender have a considerable effect on the clinical decision making of the nursing and midwifery students. Therefore, the confounding factors that can affect the clinical decision making of nurses should be discussed further, and strategies to address such factors should be implemented.

BACKGROUND: In the hospital setting, frailty is a significant risk factor, but difficult to measure in clinical practice. We propose a reweighting of an existing diagnoses-based frailty score using routine data from a tertiary care teaching hospital in southern Germany.
METHODS: The dataset includes patient characteristics such as sex, age, primary and secondary diagnoses and in-hospital mortality. Based on this information, we recalculate the existing Hospital Frailty Risk Score. The cohort includes patients aged ≥ 75 and was divided into a development cohort (admission year 2011 to 2013, N = 30,525) and a validation cohort (2014, N = 11,202). A limited external validation is also conducted in a second validation cohort containing inpatient cases aged ≥ 75 in 2022 throughout Germany (N = 491,251). In the development cohort, LASSO regression analysis was used to select the most relevant variables and to generate a reweighted Frailty Score for the German setting. Discrimination is assessed using the area under the receiver operating characteristic curve (AUC). Visualization of calibration curves and decision curve analysis were carried out. Applicability of the reweighted Frailty Score in a non-elderly population was assessed using logistic regression models.
RESULTS: Reweighting of the Frailty Score included only 53 out of the 109 frailty-related diagnoses and resulted in substantially better discrimination than the initial weighting of the score (AUC = 0.89 vs. AUC = 0.80, p < 0.001 in the validation cohort). Calibration curves show a good agreement between score-based predictions and actual observed mortality. Additional external validation using inpatient cases aged ≥ 75 in 2022 throughout Germany (N = 491,251) confirms the results regarding discrimination and calibration and underlines the geographic and temporal validity of the reweighted Frailty Score. Decision curve analysis indicates that the clinical usefulness of the reweighted score as a general decision support tool is superior to the initial version of the score. Assessment of the applicability of the reweighted Frailty Score in a non-elderly population (N = 198,819) shows that discrimination is superior to the initial version of the score (AUC = 0.92 vs. AUC = 0.87, p < 0.001). In addition, we observe a fairly age-stable influence of the reweighted Frailty Score on in-hospital mortality, which does not differ substantially for women and men.
CONCLUSIONS: Our data indicate that the reweighted Frailty Score is superior to the original Frailty Score for identification of older, frail patients at risk for in-hospital mortality. Hence, we recommend using the reweighted Frailty Score in the German in-hospital setting.

The tragic COVID-19 pandemic affected many children worldwide. Among the factors that may influence the course of viral infections including COVID-19, it is still uncertain whether atopy has a protective or predisposing role. The study aims to address the knowledge gap by investigating the prevalence and severity of COVID-19 among atopic children in Kerman, in 2022. A descriptive-analytical cross-sectional study on children with a history of atopy was performed in Kerman Medical University. Demographic information, type of atopy (including allergic rhinitis, Hyper-Reactive Airway Disease (HRAD) or asthma, eczema, urticaria, anaphylaxis, and food allergy), history of COVID-19 infection, and disease severity were recorded. A total of 1007 children and adolescents, (boys: 56.4%, girls: 43.6%, age:5.61±2.64 years) were included in the study. History of COVID-19 infection was positive in 53.5%, with 75.9% of the cases exhibiting mild disease severity. The frequency of atopies was HRAD or asthma (67.2%), allergic rhinitis (42.6%), and food allergy (27.4%). The frequency of COVID-19 cases was significantly higher among patients with HRAD or asthma, whereas it was significantly lower among those with food allergies, anaphylaxis, and eczema. Among atopic individuals, COVID-19 severity was significantly lower in those with allergic rhinitis, while the opposite trend was observed among food-allergic individuals. This study sheds light on the relationship between atopy and COVID-19 among pediatric patients. It seems specific types of atopies may influence the risk and severity of COVID-19 infection differently. A better understanding of these associations can inform clinical management and preventive measures for vulnerable pediatric populations.

Weaning and liberation from VA ECMO in cardiogenic shock patients comprises a complex process requiring a continuous trade off between multiple clinical parameters. In the absence of dedicated international guidelines, we hypothesized a great heterogeneity in weaning practices among ECMO centers due to a variety in local preferences, logistics, case load and individual professional experience. This qualitative study focused on the appraisal of clinicians\' preferences in decision processes towards liberation from VA ECMO after cardiogenic shock while using focus group interviews in 4 large hospitals. The goal was to provide novel and unique insights in daily clinical weaning practices. As expected, we found we a great heterogeneity of weaning strategies among centers and professionals, although participants appeared to find common ground in a clinically straightforward approach to assess the feasibility of ECMO liberation at the bedside. This was shown in a preference for robust, easily accessible parameters such as arterial pulse pressure, stable cardiac index ≥2.1 L/min, VTI LVOT and \'eyeballing\' LVEF.

BACKGROUND: Primary curative treatment of resectable laryngeal cancer includes surgery and chemoradiotherapy. Other treatment options include radiotherapy, chemoradiotherapy, partial laryngectomy, and total laryngectomy. Larynx-preserving treatments (partial laryngectomy, radiotherapy, and chemoradiotherapy) are recommended in early stage cases, although total laryngectomy is needed in advanced cases. Here, we evaluated trends in treatment strategies and identified the factors that are important in decision making.
METHODS: We performed a retrospective analysis of data acquired from electronic medical records in Japan. Hospitalized laryngeal cancer patients admitted between January 2014 and December 2018 were included in our analyses. The primary outcome was the initial treatment.
RESULTS: A total of 363 patients (mean age 71.8 ± 9.5, male/female = 333/30) met the inclusion criteria. Of these, 10.1% of the patients were treated with total laryngectomy, while 17.9% underwent partial resection, 65.8% received radiotherapy (chemoradiotherapy), and 6.1% had no treatment. Larynx-preserving treatment was used in most T1-2 cases (96.9%), and 40% of the patients with T3 cancer underwent total laryngectomy (adjusted odds ratio 26.7 [95% CI, 9.29-91.6]). Of the T3 cancers that were treated, total laryngectomy was performed in only 26.7% of patients aged ≤65 years, but in more than 50% of those aged >65 years.
CONCLUSIONS: This retrospective study showed that larynx-preserving treatments were used in most T1-2 cases, and suggested that T stage is the most important factor affecting decision making in the treatment of laryngeal cancer. Older patients with T3 disease tended to undergo total laryngectomy, and age is an important factor in the decision-making process for cases of T3 laryngeal cancer.

OBJECTIVE: To undertake a comprehensive investigation into both the process of information acquisition and the clinical decision-making process utilized by primary care nurses in the course of treating chronic wounds.
METHODS: Scenario-based think-aloud method, enriched by the integration of information processing theory. The study was conducted within the framework of home care nursing organizations situated in Flanders, the Flemish speaking part of Belgium. A cohort of primary care nurses (n = 10), each possessing a minimum of one year of nursing experience, was recruited through the collaboration of three home care nursing organizations.
METHODS: Two real-life clinical practice scenarios were employed for the interviews, with the researcher adopting the roles of either the patient or another clinician to enhance the realism of the think-aloud process. Each think-aloud session was promptly succeeded by a subsequent follow-up interview. The Consolidated criteria for Reporting Qualitative research checklist was followed to guarantee a consistent and complete report of the study.
RESULTS: Amidst noticeable variations, a discernible pattern surfaced, delineating three sequential concepts: 1. gathering overarching information, 2. collecting and documenting wound-specific data, and 3. interpreting information to formulate wound treatment strategies. These concepts encompassed collaborative discussions with stakeholders, while the refinement of wound treatment strategies was interwoven within both concepts 2 and 3.
CONCLUSIONS: Evident variations were identified in chronic wound care clinical decision-making, regardless of educational background or experience. These insights hold the potential to inform the development of clinical decision support systems for chronic wound management and provide guidance to clinicians in their decision-making endeavours.

Given that AI-driven decision support systems (AI-DSS) are intended to assist in medical decision making, it is essential that clinicians are willing to incorporate AI-DSS into their practice. This study takes as a case study the use of AI-driven cardiotography (CTG), a type of AI-DSS, in the context of intrapartum care. Focusing on the perspectives of obstetricians and midwives regarding the ethical and trust-related issues of incorporating AI-driven tools in their practice, this paper explores the conditions that AI-driven CTG must fulfill for clinicians to feel justified in incorporating this assistive technology into their decision-making processes regarding interventions in labor.
This study is based on semi-structured interviews conducted online with eight obstetricians and five midwives based in England. Participants were asked about their current decision-making processes about when to intervene in labor, how AI-driven CTG might enhance or disrupt this process, and what it would take for them to trust this kind of technology. Interviews were transcribed verbatim and analyzed with thematic analysis. NVivo software was used to organize thematic codes that recurred in interviews to identify the issues that mattered most to participants. Topics and themes that were repeated across interviews were identified to form the basis of the analysis and conclusions of this paper.
There were four major themes that emerged from our interviews with obstetricians and midwives regarding the conditions that AI-driven CTG must fulfill: (1) the importance of accurate and efficient risk assessments; (2) the capacity for personalization and individualized medicine; (3) the lack of significance regarding the type of institution that develops technology; and (4) the need for transparency in the development process.
Accuracy, efficiency, personalization abilities, transparency, and clear evidence that it can improve outcomes are conditions that clinicians deem necessary for AI-DSS to meet in order to be considered reliable and therefore worthy of being incorporated into the decision-making process. Importantly, healthcare professionals considered themselves as the epistemic authorities in the clinical context and the bearers of responsibility for delivering appropriate care. Therefore, what mattered to them was being able to evaluate the reliability of AI-DSS on their own terms, and have confidence in implementing them in their practice.